Pediatric Atopic Dermatitis: Skin-Directed Approach Key

Diedtra Henderson

November 24, 2014

Because atopic dermatitis (AD) results from abnormalities in the skin barrier, skin-directed management is "of paramount importance," according to a clinical report aimed at pediatricians who are most likely to diagnose and treat the dermatologic condition in children.

Megha M. Tollefson, MD, lead author for the clinical report, Anna L. Bruckner, MD, and the Section on Dermatology Executive Committee of the American Academy of Pediatrics published their guidance online November 24 in Pediatrics.

At least 10% of American children suffer from AD, also known as eczema, with 85% of disease onset occurring before age 5 years, according to the clinical report. The inflammatory skin ailment is characterized by chronic, relapsing lesions, which patients and parents call the "itch that rashes."

In infants, the cheeks, scalp, trunk, and extremities are most often affected, according to Dr Tollefson and colleagues. By early childhood, the flexural areas are more heavily affected, and in adolescents and adults, hands and feet are most often involved.

Because there are few pediatric dermatologists, the burden of care falls on primary care providers. However, parents may find frustrating differences in clinical practices and a confusing array of advice about bathing, use of moisturizers, and topical medication. Another source of frustration is that the disease can flare even when care plans are excellent and faithfully carried out.

For nearly 50% of patients, AD exacts a "severely negative" toll on quality of life, disrupting sleep and limiting their activities, resulting in fatigue, depression, and dampened social life. According to the authors, parents whose children have moderate and severe AD can spend up to 3 hours daily caring for their child's skin.

Although most parents wrongly blame food allergies as the sole trigger for eczema, mutations in filaggrin (FLG), which encodes for a protein that is integral to the structure and formation of the outermost layer of the skin, have been associated with a two- to threefold increased AD risk.

As such, the guidelines say skin-directed therapies should be the first approach to AD management. Each day, parents should maintain skin hydration and avoid irritants or triggers. Daily baths in lukewarm water can be helpful, as are mild, synthetic detergents free of fragrance, provided the baths are accompanied by a postsoak moisturizer. Parents should match the frequency of baths to the patient's response to the bath.

Frequent use of moisturizer reduces discomfort, helps repair the skin barrier, and has been shown to reduce reliance on moderate or potent topical steroids. Parents should apply moisturizer at least once daily on all skin, even unaffected skin. In terms of moisturizing effect, ointments, which have the highest lipid proportion, rank first, followed by creams and then lotions. Preservatives and fragrances can be potential irritants. Other triggers can include harsh soap, rough fabric, sweat, and stress.

Finally, topical steroids, which attack the skin's inflammatory immune response, are "effective and safe" when used appropriately. Parents can combine wet dressings with topical steroids for acute flares.

Clinicians should refer patients who do not respond to the treatment plans outlined in the report to a specialist.

"Although the pathogenesis of AD is complex, recent research advances support the role of an abnormal skin barrier," the authors conclude. "The clinical corollary to these discoveries is a greater focus on skin-directed therapies as the first-line treatment of children with AD."

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online November 24, 2014.

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